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© 2014 New Hampshire Orthopaedic Center
Elbow injuries in adolescent athletes have gained quite a bit of attention over the last decade with increased sports participation, physician awareness, and media attention. There has also been an alarming rate of increased surgical procedure performed in younger athletes in that timeframe.
The ulnar collateral ligament is a 3 part ligament on the inside part of the elbow that connects the upper arm to one of the forearm bones (ulna). It provides stability to the hinge joint of the elbow resisting the outward directed stress placed on the elbow during the throwing motion. Pitching a baseball has been shown to generate forces at the elbow very close to the ultimate strength of the ulnar collateral ligament, which over time and repetition, can lead to failure of the ligament.
Some patients may report an actual “pop” felt while throwing, which would represent an acute (sudden) injury to the ligament. Many others will describe a vague pain, consistent in its location and during the late cocking and early acceleration phase of the throwing motion. This is more consistent with a chronic attenuation (thinning) of the ligament. Some may also describe some nerve symptoms, such as numbness or tingling into the fingertips (from the ulnar or “funny bone)nerve). It’s important to also know the patients history of position played, frequency of play, number of pitches, prior treatments and offseason regimen.
Four potential risk factors for elbow (and shoulder) injuries in youth baseball have been identified: Number of pitches thrown (in a game, season, and year), type of pitches, pitching mechanics, and physical condition. The number of pitches thrown seems to be the most important. Recent studies have suggested that the curveball may not be any more dangerous than any of the other pitches, and that the change up is likely the safest. Pitch counts were mandated by Little League Baseball many years ago based on these studies and can be found at www.littleleague.org. Pitching outside of the league makes tracking some of these things difficult, as many young athletes will play on multiple teams in different leagues who may not follow these guidelines.
The first testing should be a thorough physical exam by a Sports Medicine Fellowship trained Orthopaedic Surgeon. If an ulnar collateral ligament injury is suspected, after some screening x-rays are performed, an MRI scan may be warranted. This is a test that will demonstrate the soft tissues around the elbow.
A trial of non-surgical management is encouraged, especially in the young adolescent athlete. This usually consists of at least 6 weeks of no throwing as we begin physical therapy. There are often many areas of deficiency to address, including motion deficits of the shoulder, pitching mechanics, weakness of the core and kinetic chain (the center of the body (hips, abdominal, gluteal, back) and legs) as well as the shoulder. Once these deficits have been identified and addressed, then a VERY gradual, SUPERVISED throwing program may begin. The patient must remain pain free through this course and progression to be able to return to competition. In the event that this fails, or that the tear is complete on evaluation, surgery may be required if the patient is still planning to play, and to pitch. Surgery is reconstructive, which means the ligament is replaced by a tendon graft connecting the two bones. Often a tendon from the forearm or the opposite hamstring (at the knee) is used. Rehabilitation is long and deliberate and a return to competitive throwing is expected 9-12 months after surgery. Outcomes from surgery reveal a very high rate of return to the same level of competition. However, a very recent report from the American Orthopedic Society for Sports medicine in Major League pitchers shows a trend toward a higher ERA, WHIP (walks and hits per inning pitched), and innings pitched thereafter. Very few, if any, adolescent pitchers requiring this surgery will ever make it to the Major League level. Below are some useful guidelines from USA Baseball.
MRI: Not the Whole Story
William P. Rix, MD
MRI is an imaging tool commonly used by orthopedists in making a diagnosis in patients with musculoskeletal complaints. It is frequently mentioned in the media when professional athletes are injured:
“Major League Baseball pitcher John Smith’s production has fallen over the past few games. MRI of his sore shoulder reveals no structural damage and rest is indicated.”
“National Football League lineman Jim White’s episodes of low back pain have limited his starts this season. An MRI showed he will need surgery and will be out for the rest of the season”.
The implication of these common references in the sports media is that an MRI offers the definitive answer for musculoskeletal problems.
MRI is a state-of-the-art imaging technique that depicts the anatomy of our musculoskeletal system in astonishing detail. Despite its unquestionable value, however, it can be confusing and in some cases, downright misleading. This is because the abnormality seen on the scan may not be the cause of the patient’s problem. Remarkable as the technology is, it is no substitute for a good history and physical examination.
To illustrate, let’s look at some actual cases:
In all three cases, the MRI showed a true structural abnormality that could be corrected surgically. However, one does not operate on an abnormality just because it`s there. It has to be the cause of the patient`s problem. The MRI did not tell the physician if the findings seen on film were actually causing the patient’s symptoms. An MRI cannot stand by itself. It must be ordered and interpreted in the context of a proper history and exam. In these patients, the MRI findings were age-related or post-surgical and not contributing to their complaints.
The proper sequence in arriving at the root of a patient’s orthopedic problem is a thorough history, a proper examination and, usually, an x-ray. If further investigation is needed to come to a specific diagnosis, further testing, including MRI is then employed.
Since the time of Hippocrates, the backbone of delivering good patient care has been the history and physical. It still is.
What are they?
A concussion is an injury to the brain that alters its function, the effects of which are usually temporary. These effects are variable and can include difficulty with concentration, memory, balance, and coordination.
These can range from very subtle, to obvious and severe. Headache, loss of memory, and confusion are often seen. Loss of memory can include events prior to the injury and will often include loss of memory of how the injury occurred.
MOST CONCUSSIONS DO NOT RESULT IN LOSS OF CONSCIOUSNESS.
Things to look for include:
Seizures, altered vision, pupils that don’t appear symmetric, or prolonged loss of consciousness require immediate evaluation
The brain is a very delicate structure encased in a solid container (skull). Anything that causes the brain to knock up against the side of the skull may result in a concussion. A DIRECT BLOW TO THE HEAD IS NOT REQUIRED TO RESULT IN A CONCUSSION, NOR IS DIRECT CONTACT. Rapid deceleration of the head can cause the brain to hit the skull and result in a concussion.
Participation in collision sports such as lacrosse (in this case) is a risk factor. Another very important risk factor is having had a previous concussion.
On field evaluation includes evaluating consciousness and protecting any neck injury. There are various sideline tools used to assess the athletes symptoms and ability to recall or think. These are brief screening tools for the in-game setting which are usually followed by more comprehensive neurocognitive testing.
There is no routine x-ray or medical test to diagnose concussion. CT SCANS AND MRIs ARE TYPICALLY NORMAL with a concussion. If a patient develops specific neurological symptoms such as prolonged or worsening pain, loss of vision, asymmetric pupils, repeated vomiting or seizures CT scans and/or MRI can tell if there is bleeding on the brain that may be the cause.
1. “When in doubt, keep ‘em out”. The first step is removing the athlete from participation as soon as a concussion is suspected.
2. Rest. This includes rest from both physical and mental activity. This includes all “thinking” activities like reading, video games, TV, etc.
3. Tylenol (acetaminophen) is useful for headaches, but NSAIDs such as Ibuprofen (Motrin, Advil), Aleve, and Aspirin are NOT recommended, as this may increase the risk of bleeding.
4. Progression back to activity begins with mental activity first.
5. Some studies have suggested that gentle exercise that keeps the athlete below their symptom threshold might help decrease the possibility of post concussion syndrome and help both athletes and non-athletes return to activity.
Return to Play
Most athletes will have resolution of symptoms after two weeks and a return of their neurological testing to a baseline (“normal”) in 7-10 days. Internationally accepted return to play criteria includes:
Once an athlete has no symptoms at rest, they can then progress through a guided protocol of rehab to return to play. Each stage takes 24 hrs, so that it takes at least 5 days to progress through the protocol prior to full game participation.
Preventative measures are of paramount importance in high risk sports. Players, Coaches, and parents have a role to play in not only recognition of sports concussions, but in changing the behavior and culture that may result in concussion. Many players, coaches, and parents may feel like aggressive behavior is required in certain sports. These feelings are often heard expounded from the sidelines. Proper technique, age appropriate rules for contact, and sportsmanship can result in decreased incidence of concussions.
Helmets and new helmet technology have been shown to decrease the risk of concussion and newer technologies are promising.
There is lack of conclusive evidence that the use of a mouth guard or specific types of mouth guards reduce the risk of concussion. Mouth guards do, however, reduce the risk of dental trauma which makes them invaluable in that role.
Post Concussion Syndrome is the persistence of any of the following after a concussion: headaches, dizziness, fatigue, irritability, difficulty with concentration and mental tasks, memory impairment, insomnia, and reduced tolerance to stress. It’s suspected if these symptoms persist more than 1-6 weeks after initial injury. Athletes who present initially with more symptoms take longer to recover.
Epilepsy: The risk of developing Epilepsy is doubled in the first 5 years post concussion.
Second Impact Syndrome: This is when an athlete sustains 2 successive injuries before recovery of the first is complete. Younger athletes seem especially susceptible to this, which can be a devastating complication leading to rapid brain swelling and death. Second Impact Synrome highlights the importance of restricting athletes from play until they have NO SYMPTOMS.
CTE (Chronic Traumatic Encephalopathy): This is a degenerative condition of the brain that occurs years after recovery. It is the topic of much conversation and research. Early in CTE, patients can have problems with irritability, depression, and poor memory. Later on, it can affect physical movement and speech. (See Junior Seau, Jim McMahon, both former NFL players)
There are multiple resources available for education for players, parents, coaches, and trainers on this topic which include programs for preseason baseline testing for players which is instituted in many local high schools and routinely at the collegiate and professional levels.
|NCAA Concussion in Sports||www.ncaa.org/health-and-safety/medical-conditions/concussion|
|Centers for Disease Control and Prevention Heads Up Toolkit for High School Sports||www.cdc.gov/concussion/HeadsUp/high_school.html|
|Centers for Disease Control and Prevention Heads Up Toolkit for Schools||www.cdc.gov/concussion/HeadsUp/schools.html|
|Centers for Disease Control and Prevention Heads Up Toolkit for Physicians||www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html|
|Computerized neuropsychological tests|
|U.S. Army Medical Department, Automated Neurocognitive Assessment Metrics (ANAM)||www.armymedicine.army.mil/prr/anam.html|
**The Journal of Bone and Joint Surgery Current Concepts Review, Vol 94, Issue 17
Another I would add to this is sportslegacy.org, which is an organization headed by Chris Nowinski and Dr. Robert Cantu with cutting edge education and policy on this enormously important matter. There are several links and guides to setting up and maintaining an active concussion surveillance and management program for teams and institutions.
What Is It?
An overuse syndrome resulting in painful inflammation at the top of the shin bone where the patellar tendon attaches to the bone in an adolescent or preadolescent athlete.
This condition is marked by pain and tenderness with or without (usually with) a bump at the top of the shinbone (tibia). The pain is often increased with activity (or just after finishing the activity), and is often relieved with rest. It may be associated with a noticeable tightness in the muscles in the front and in the back of the thigh.
An apophysis is a growth plate that does not contribute to the length of a bone. Growth plates are made of cartilage. Cartilage is weaker than bone in the immature skeleton. Apophyses are often found at sites where tendons attach to bone. Apophysitis is inflammation at these attachment sites, the adult equivalent of which is tendonitis.
Repetitive activities, such as jumping, running, pivoting, etc. , coupled with a child who is growing, can lead to increase pull and tension on these delicate areas. This leads to pain and inflammation in those areas. The body may attempt to repair these areas by forming more bone, leading to a lump forming.
Osgood-Schlatters is a clinical diagnosis. A plain X-ray is often obtained to rule out other less common problems and to sometimes confirm the diagnosis. MRI IS NOT NECESSARY TO DIAGNOSE THIS CONDITION.
When I see patients in the office with knee or hip pain, I am often asked, “Do I need an MRI?” and “I had an MRI, why do I need X-rays?”
There are many different imaging studies that physicians use to evaluate painful or injured joints. An X-ray is typically the first study that is obtained. Why do we get X-rays if other tests, like an MRI, show more detail? Different images give different information. X-rays are best for looking bones. Fractures can be seen in more detail on an Xray than on an MRI, for example. Moderate and severe arthritis can also be better visualized on X-rays. A CT scan is a special type of X-ray which gives three dimensional cross sectional images. It is excellent at evaluating bony anatomy. However, it does expose patients to quite a bit of radiation.
In contrast, an MRI images soft tissues (such as ligaments and meniscus) more clearly than X-rays. No radiation is used to create the images obtained by an MRI. A very strong magnetic field is used to obtain the images. An MRI takes about an hour to perform and requires the patient to lay very quietly in a narrow tube. Unlike an X-ray, only one body part can be imaged at a time. It takes twice as long to do an MRI of two knees compared to only one. Some people are unable to have an MRI because of metal implants (stents in heart or brain), pacemakers or claustrophobia.
When do you need an MRI? An MRI should be used to look for a specific abnormality suspected based on history or physical exam. Examples include rotator cuff tears, meniscal tears, labral tears, avascular necrosis, or ligament tears.
Many patients with arthritis wonder, ‘Why I do not need an MRI to diagnosis arthritis or to plan a knee or hip replacement?’ X-rays are better at evaluating end stage arthritis than MRIs. If you have arthritis on an x-ray, an MRI will likely not change the treatment recommendations and therefore is not needed. It is also important to know that just because a test is abnormal does not mean that the pain is caused by the abnormality. For example, if an MRI of the knee shows a torn meniscus on the outside of the knee but the patient’s pain is on the inside part of the knee, that torn meniscus is not causing the pain.
There are many imaging tests available to help physicians diagnose the cause of joint pain. Usually there is not one definitive test that gives an answer, but a combination of physical exam and diagnostic studies which leads to a diagnosis. While MRI can be helpful, it is not always needed.
© 2014 New Hampshire Orthopaedic Center